Best Practices in Recognition, Diagnosis, and Treatment of Circadian Rhythm Disorders: A Cases & Commentary™ Workshop for Primary Care Clinicians

Overview:

Circadian rhythm disorders (CRDs) are prevalent, underrecognized, and inadequately treated, due in part to their varied symptomatology and to the lack of assessment skills among clinicians in the primary care setting. CRDs reflect misalignment between the biologic sleep/wake cycle and environmental demands, and/or between the biologic clock and societal norms for bedtime and wake time. Characterized by insomnia and excessive sleepiness, circadian dyssynchrony is debilitating across numerous cognitive, affective, and physiologic domains. CRDs comprise several distinct subtypes, including shift work disorder (the most clinically significant and prevalent), advanced sleep phase disorder, and delayed sleep phase disorder. Short-term consequences stemming from CRDs can be severe, including impaired cognition, motor vehicle accidents, and medical errors among healthcare professionals. More alarming perhaps are recent studies among patients with CRDs suggesting an important link to cardiometabolic dysfunction, gastrointestinal disturbances, and mood/affective disorders. Primary care clinicians are faced with the need to provide an accurate diagnosis and initiate appropriate treatment for CRDs to avoid the long-term health implications associated with these disorders, and to ascertain patient and public safety.

Employing a case-based format, the Cases & Commentary™ workshop will foster peer-to-peer interaction between participants and expert facilitators. Participants will be presented with case studies representative of the myriad issues in managing patients with CRDs. Each case study will invite commentary from peers and expert facilitators. Upon reviewing salient data—including physical examination history, risk factors, comorbidities, and prior medical and treatment history—participants will develop a course of action in step-by-step fashion for patients presenting with CRDs. Participants will benefit from the peer-to-peer design of the roundtable discussions, which allows them the opportunity to listen, probe, and propose solutions with their peers. For those participants whose approach to decision making is aligned with that of their peers and thought leaders, the workshop will validate current practice.

Commercial Support:  Cephalon, Inc.

Learning Objectives:

• Formulate a comprehensive and accurate approach to initial assessment of circadian rhythm disorders, based on the pathophysiology of circadian rhythm dyssynchrony and its consequences on sleep symptoms, as well as on metabolism, cardiac function, cognition, and mood

• Perform focused initial assessments with patients identified to have shift work disorder and other circadian rhythm disorders based on their telltale symptomatology

• Formulate initial treatment plans for shift work disorder, advanced sleep phase disorder, and delayed sleep phase disorder based on etiology and pathophysiology, and assessment of patient comorbidities, age, medical history, and level of impairment
  
  
• Monitor treatment responsiveness (improved Epworth Sleepiness Scale score and/or sleep log, affect, cognition, and function) for patients with shift work disorder and other circadian rhythm disorders at 1-month follow-up from initial visit, and as needed, for improved long-term management and patient outcomes

Best Practices Pearls:

• Obtain a sleep history. Characterize the patient’s sleep pattern including sleep quality and quantity on work days, weekends, and long holidays using a focused patient interview and sleep log/diary.

• What time do you go to bed?
• How long does it take you to fall asleep?
• Do you wake up after falling asleep?
• Do you feel rested after you sleep?
• What time do you wake up?

• Determine the effects of sleep problems on quality of life during wake time. Inquire about a patient’s sleepiness, performance deficits, cognitive impairment, and mood.

• Recognize excessive sleepiness and insomnia as cardinal signs and symptoms of CRDs, which may adversely affect organ systems, and associated morbidities including cardiometabolic dysfunction, gastrointestinal disturbances, and mood/affective disorders.

• Treat CRDs with behavioral and scheduling changes, appropriately timed light, and various pharmacologic approaches as necessary.

Accreditation: ACCME

Primary Care Network, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Primary Care Network designates this educational activity for a maximum of 2.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.